We have a patient, 63 F. presenting with lower abdominal pain (R > L), anorexia of sudden onset two weeks ago. WBC 21,000. She is a hypertensive smoker, has emphysema and some renal insufficiency (creatinine 2- 2.5). Before referral, a provisional diagnosis of diverticulitis had been made, based on clinical picture and BE showing primarily sigmoid tics, though CT showed no evidence of inflammatory bowel changes or abscess/phlegmon. It did, however, show a 5cm thoracic/ 4cm abdominal aneurysm on review, together with non-dilated fluid-filled small bowel and right colon! She had initially improved on bowel rest, IV hydration and antibiotics, with WBC down to 14,000, though never became pain-free and had increased pain when oral intake was resumed.

Angiography was technically difficult, but suggested a small infradiaphragmatic dissection. SMA and celiac axis patent but ostia poorly visualised and unable to selectively catheterise. IMA not visualised. Subsequent medical control of her hypertension to 120's systolic, plus beta blocker was accompanied by increased abdominal pain, rebound tenderness and WBC elevation to 28,000 prompting laparotomy to rule out ischemic/dead bowel.

Small bowel from one meter distal to Trietz, and cecum/ ascending colon were ischemic but viable. Pulses in SMA decreased significantly but flow present by doppler. No signs of embolism. Remaining colon and small bowel normal. Closed and patient treated by aggressive optimization of cardiac output, monitored by SG catheter, with improvement.

- Is the thoracic aneurysm separate from abdominal portion or is it a true thoraco-abdominal aneurysm? At this point it doesn't matter to much but it may make a difference down the road if she survives.

- You should be able to tell if a dissection is present on the CT scan if contrast was used.

- Intra-operative Doppler can be misleading. Did you dissect out the SMA and its branches? What did it feel like? Could you feel thrombotic plaque at the oriface?

- Given that the patient is high risk, with a 4cm abdominal AAA and questionable SMA and celiac orifaces, I don't think you had much choice in dealing only with the bowel.

The aneurysm has a narrower segment at the diaphragm with the abdominal portion arising just below (high suprarenal), and the thoracic portion extending to just above the diaphragm. We did not fully dissect out the SMA right to its origin, but there is calcified plaque palpable near the origin. The aorta at this area feels soft and aneurysmal.

Since the original letter, the patient has improved remarkably with careful optimization of her cardiac output and oxygen delivery. We have started to back off a little, and she is beginning to eat, without mesenteric angina. Thus, we have not re-explored.